My wife is dying ...

[Handsome Robb]

It sounds like Lupus to me.


Sent from my iPhone using Tapatalk

 

[SpecialK]

Roses are red,
Violets are blue,
She looks like,
Someone who has hypovolemia

Ask yourself ... do patients with hypovolaemia normally present with a rapid onset of very severe shock? If her normal blood pressure is for example 120 (assuming she has not developed maternal HTN) then for her BP to now be 70 or 80 means it's about a third less than normal which is a large change in such a short amount of time assuming her blood volume is normal (and indeed, don't pregnant women get an enlarged circulating volume anyway?).

We cannot say for sure without opening her belly up or doing USS, but there are a number of factors which point away from hypovolaemia:

(1) The very fast onset. The husband said it happened 20 minutes ago when the ambulance first arrived; so if it took the ambulance 10 minutes to drive there, then in reality, it happened 10 minutes after she gave birth. He told Control it looked like "my wife is dying" so presuming she looks pretty much the same as she did then when the ambulance first arrived, she hasn't progessed much. This means she went from essentially being well to critically unwell in a very short space of time (a few minutes).

(2) The lack of visible blood. Granted bleeding can be internal; she would have to lose a litre or more I imagine in one go to look this sick from hypovolaemia in such a short space of time. I didn't mention it but I'd also give her some IM oxytocin and do fundal massage as well as IV fluid in case she had uterine haemorrhage. In this case, if that is done, she doesn't improve. That would further point away from hypovolaemia.

(3) Her lung sounds. This is the "clincher" that points strongly towards an anaphylaxis-like reaction. If we "put aside" the fact she is pregnant and has just given birth, anybody else who has a history of severe shock which came on very rapidly and wheezy lungs screams at the top of their, well wheezy lungs, "anaphylaxis" no? Surely you must agree?

The balance of risk here, as well as all other things we are doing to her, is giving her some adrenaline no? If can't hurt, and it might be the thing which saves her life? Which in this case, it was!

 

[Alan L Serve]

Ask yourself ... do patients with hypovolaemia normally present with a rapid onset of very severe shock? If her normal blood pressure is for example 120 (assuming she has not developed maternal HTN) then for her BP to now be 70 or 80 means it's about a third less than normal which is a large change in such a short amount of time assuming her blood volume is normal (and indeed, don't pregnant women get an enlarged circulating volume anyway?).

We cannot say for sure without opening her belly up or doing USS, but there are a number of factors which point away from hypovolaemia:

(1) The very fast onset. The husband said it happened 20 minutes ago when the ambulance first arrived; so if it took the ambulance 10 minutes to drive there, then in reality, it happened 10 minutes after she gave birth. He told Control it looked like "my wife is dying" so presuming she looks pretty much the same as she did then when the ambulance first arrived, she hasn't progessed much. This means she went from essentially being well to critically unwell in a very short space of time (a few minutes).

(2) The lack of visible blood. Granted bleeding can be internal; she would have to lose a litre or more I imagine in one go to look this sick from hypovolaemia in such a short space of time. I didn't mention it but I'd also give her some IM oxytocin and do fundal massage as well as IV fluid in case she had uterine haemorrhage. In this case, if that is done, she doesn't improve. That would further point away from hypovolaemia.

(3) Her lung sounds. This is the "clincher" that points strongly towards an anaphylaxis-like reaction. If we "put aside" the fact she is pregnant and has just given birth, anybody else who has a history of severe shock which came on very rapidly and wheezy lungs screams at the top of their, well wheezy lungs, "anaphylaxis" no? Surely you must agree?

The balance of risk here, as well as all other things we are doing to her, is giving her some adrenaline no? If can't hurt, and it might be the thing which saves her life? Which in this case, it was!

Yes, my friend.

For the reasons I described, above.

Have a blessed evening. I'm going to study HVAC now.

 

[ERDoc]

And you,

my friend,

are my dearest friend.

No, I am the ER doctor that has to try to salvage what is left of this poor women when you finally get her to the ER

Ask yourself ... do patients with hypovolaemia normally present with a rapid onset of very severe shock? If her normal blood pressure is for example 120 (assuming she has not developed maternal HTN) then for her BP to now be 70 or 80 means it's about a third less than normal which is a large change in such a short amount of time assuming her blood volume is normal (and indeed, don't pregnant women get an enlarged circulating volume anyway?).

We cannot say for sure without opening her belly up or doing USS, but there are a number of factors which point away from hypovolaemia:

(1) The very fast onset. The husband said it happened 20 minutes ago when the ambulance first arrived; so if it took the ambulance 10 minutes to drive there, then in reality, it happened 10 minutes after she gave birth. He told Control it looked like "my wife is dying" so presuming she looks pretty much the same as she did then when the ambulance first arrived, she hasn't progessed much. This means she went from essentially being well to critically unwell in a very short space of time (a few minutes).

(2) The lack of visible blood. Granted bleeding can be internal; she would have to lose a litre or more I imagine in one go to look this sick from hypovolaemia in such a short space of time. I didn't mention it but I'd also give her some IM oxytocin and do fundal massage as well as IV fluid in case she had uterine haemorrhage. In this case, if that is done, she doesn't improve. That would further point away from hypovolaemia.

(3) Her lung sounds. This is the "clincher" that points strongly towards an anaphylaxis-like reaction. If we "put aside" the fact she is pregnant and has just given birth, anybody else who has a history of severe shock which came on very rapidly and wheezy lungs screams at the top of their, well wheezy lungs, "anaphylaxis" no? Surely you must agree?

The balance of risk here, as well as all other things we are doing to her, is giving her some adrenaline no? If can't hurt, and it might be the thing which saves her life? Which in this case, it was!

All good points. Keep in mind what has just happened to this woman. She had a huge, firm object (the baby) forcefully pushed through a small passageway (the cervix and vagina), creating a nice open pathway with little resistance to the flow of blood. The only other pathway out of the uterus is the fallopian tubes which are very small and provide significant resistance to blood flow through them. There is no way this woman lost enough blood through her tubes to account for the degree of shock she is in. The only other natural pathway is out the cervix/vagina and we know she hasn't lost enough blood there. Now we have to think of some disasters that may have happened that has caused hypovolemia. The only one really would be a uterine rupture. There is no reason to think uterine rupture in this case. The baby delivered with little easy, there no risk factors and she is not having any abd pain that is out of the ordinary. You also wouldn't see the resp issues with a rupture that quickly.

 

[Alan L Serve]

No, I am the ER doctor that has to try to salvage what is left of this poor women when you finally get her to the ER

I pray you will forgive me,
my most lovely friend,
in that I don't believe you to be,
as ER doctor.

 

[Akulahawk]

I pray you will forgive me,
my most lovely friend,
in that I don't believe you to be,
as ER doctor.

We're lucky to have this ER Doctor as a member of our forum. While there are occasionally things that he says that we may disagree with, consider that in this case, the majority of the members here are posting things that are pretty much inline with each other, leaving you as the outlier. Clearly you maintain that this patient is hypovolemic. If this is the case, where's the source of bleeding? Think about something here since this is your position: If this patient truly had suffered massive blood loss within 10 minutes of giving birth to the point where SBP pretty much is in the tank starting off with basically a normal BP, wouldn't this patient still be hemorrhaging massively and likely have exanguinated within 20 minutes? I haven't heard of anyone suffering such a massive injury where their blood pressure drops to some horrifically low number within minutes who is still alive and conscious 20 minutes later. Bleeding like that just doesn't magically stop like someone turning off a spigot, no it trickles to a stop because there's nothing left to leak out.

Harken back to your earliest EMT training when you were taught about the various types of shock. This patient is essentially suffering one of those types of shock and it isn't a hemorrhagic/hypovolemic shock.

Another way to think about this is: what would happen to your blood pressure if someone suddenly constricted your pulmonary arteries and veins to, say, 1/3 their usual diameter? Remember that this means a sudden and significant decrease in blood flow through an important part of the circulatory system...

 

[VFlutter]

I pray you will forgive me,
my most lovely friend,
in that I don't believe you to be,
as ER doctor.

So let's say you have a patient who is a few days post op from an Exp. Lap who was recently diagnosed with a DVT and now presents like this lady. Do you solely assume they are in hemorrhagic shock from an intra-abdominal catastrophe or do you maybe consider a massive PE with obstructive shock?

I am not sure this is even worth the argument.

 

[SpecialK]

I pray you will forgive me,
my most lovely friend,
in that I don't believe you to be,
as ER doctor.

Are you honestly that poorly educated you can't see the difference between hypovolaemia and other causes? I honestly can't think of what else it could be so I'm really not sure?

Let me try to help you understand, again

(1) This young woman gave birth normally and twenty minutes later you are on-scene where she is in profound, severe shock.
(2) If it took 10 minutes for you to respond, and two minutes for the husband to go through Control, that is 12 minutes
(3) So in reality, this all happened over the space of about eight minutes
(4) The husband told Control it looks like "my wife is dying" so this came on very rapidly (see 3. above)
(5) There is no external bleeding and about 200 ml of blood on a towel, 200 ml of bleeding doesn't cause profound, severe shock
(6) Her chest sounds wheezy (or at best approximation - could be crackles in there too). This is the "sinch" that it is not hypovolemia.
(7) Combining the degree of shock she has, the very rapid onset and her lungs all combine to point away from hypovolaemia.
(8) If you had any other patient who had not just given birth and had this degree of shock and a wheezy chest you would, I hope, think anaphylaxis
(9) AFE is a known condition with a large degree of anaphylaxis-like response and the "total scenario" fits with this.

So, whilst nothing is ever 100% in medicine, and we can never say "never", we can look at the balance of risk vs benefit in how to proceed. I'd give her some fluid, IM oxytocin and do fundal massage because she might have internal PPH but it doesn't look like it. However, the risk of doing so is quite low especially as the placenta has delivered. Critically, and I cannot express how significantly critical this is, I would also give her IV adrenaline because her clinical presentation screams "anaphylaxis". She is so shocked I doubt IM adrenaline would absorb very well and would take too long anyway. You could give it to her via dilutional aliquots or you could run as an infusion. I would personally run it as an infusion.

There have been a number of (unpublished) cases of patients with AFE who have been near-death only to make completely normal recoveries once they have received IV adrenaline. Some have also received blood but I don't think that is life-saving, certainly if I had blood I would give it to her initially instead of abnormal saline (abnormal in the sense she hasn't lost it) but I'd also give her IV adrenaline.

 

[VentMonkey]

I have no qualms about admitting that this scenario has been quite the educational endeavor for me.

 

[NysEms2117]

I have no qualms about admitting that this scenario has been quite the educational endeavor for me.

i'm learning all types of shiyte. including i have to learn a lot more... a lot lot lot more...

 

[VentMonkey]

It makes complete sense, but is yet quite remarkable in regards to the cascade of events that the obstructive (clot) shock has caused such a patient; good scenario.

 

[SpecialK]

It makes complete sense, but is yet quite remarkable in regards to the cascade of events that the obstructive (clot) shock has caused such a patient; good scenario.

I'd say more she has distributive shock (as we see in anaphylaxis),

I had honestly never heard of AFE until I saw this case. If I had seen this patient prior to knowing about it; I would gone down the route of PPH and done as above; I also like to think my clinical decision making is "good enough" to recognise she was having pseudo-anaphylaxis and give her some adrenaline however I can't say for sure because we'll never know.

But as you say, yes, it makes perfect sense.

 

[ERDoc]

I pray you will forgive me,
my most lovely friend,
in that I don't believe you to be,
as ER doctor.

You're right, I'm not but I did stay at a Holiday Inn once.

 

[SpecialK]

You're right, I'm not but I did stay at a Holiday Inn once.

Negative marks for being a d!ck and using an American joke I had to look up.

Do you normally call yourself an "ER doctor"? In Australasia it's normally "emergency medicine XXX" e.g. registrar, consultant (specialist), physician. To us saying "ER Doctor" is like a Cardiologist calling himself a "ward doctor" cos he sees pts in the cardiology ward.

Anyway, here's a good article on AFE https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2823093/

Dr Google tells me there are some moves to rename this "anaphylactoid syndrome of pregnancy" which is more befitting and will hopefully mean reduced mortality if people think of the it in terms of the primary treatment being adrenaline, not volume loading or giving treatments for PPH.

 

[StCEMT]

Dr Google tells me there are some moves to rename this "anaphylactoid syndrome of pregnancy" which is more befitting and will hopefully mean reduced mortality if people think of the it in terms of the primary treatment being adrenaline, not volume loading or giving treatments for PPH.

So question for any and all. I follow what you mean with it resembling anaphylaxis and using epi, what I found on Google was saying the same thing about it resembling that. So why is the A-OK treatment plan what I see recommended instead? Unless your article goes into detail Chase and I don't remember, admittedly I didnt have time to read it all when I opened it. Epi makes sense, but the lit says A-OK had good outcomes in many cases and is what I have seen multiple times since following this.

 

[SpecialK]

So why is the A-OK treatment plan what I see recommended instead?

Atropine 1 mg for vagolysis (needed?)
Ondansetron 8 mg to block serotonin receptors and for vagolysis
Ketorolac 30 mg to block thromboxane production

Src: http://www.marchofdimes.org/pdf/missouri/AFE_11-21-13.pdf

I had to look up what ketorolac was; I don't think it's used locally. The two patients that powepoint talks about are different; they were both in cardiac arrest.

Based on the presentation of this young woman my most important aspect of treating her would be IV adrenaline as an infusion. I guess atropine and ondansetron are part of the ambulance formulary so could technically administer them for this. It's not exactly written in the CPG but it'd still be permissible under the discretion to deviate from them.

 

[ERDoc]

Negative marks for being a d!ck and using an American joke I had to look up.

Do you normally call yourself an "ER doctor"? In Australasia it's normally "emergency medicine XXX" e.g. registrar, consultant (specialist), physician. To us saying "ER Doctor" is like a Cardiologist calling himself a "ward doctor" cos he sees pts in the cardiology ward.

LOL. Yes, I call myself an ER doctor. Most people in the US would be confused if I said I was an Emergency Medicine attending physician. A lot of people here still think ER docs are just other specialties that work extra shifts in the ER. I always get asked what I really want to do or what my real job is. There is a small movement to call us emergontologists, which I think is just stupid.

 

[Shrimpfriedrice]

I follow everything that was discussed so far. I'm sure someone can clarify this for me. So obstructive, hypovolemic, and anaphylactic shock were mentioned, but not cardiogenic. Granted she is fairly young however pregnancies take quiet the toll on the human body. I remember seeing a video of a young mother who developed cardiomyopathy that began in the 1st pregnancy and worsened in the second requiring her to receive a pacemaker.

With that said the onset of symptoms where fairly quick, i'm just suprised no one dug for more of a history? I know normally we probe for a more detailed history before providing possible differentials. Am I missing something?

 

[DesertMedic66]

I follow everything that was discussed so far. I'm sure someone can clarify this for me. So obstructive, hypovolemic, and anaphylactic shock were mentioned, but not cardiogenic. Granted she is fairly young however pregnancies take quiet the toll on the human body. I remember seeing a video of a young mother who developed cardiomyopathy that began in the 1st pregnancy and worsened in the second requiring her to receive a pacemaker.

With that said the onset of symptoms where fairly quick, i'm just suprised no one dug for more of a history? I know normally we probe for a more detailed history before providing possible differentials. Am I missing something?

What questions would you ask to dig more into the history of this patient? All of her symptoms fit AFE, if you hear hoof beats that doesn't mean there is a zebra.

 

[SpecialK]

I follow everything that was discussed so far. I'm sure someone can clarify this for me. So obstructive, hypovolemic, and anaphylactic shock were mentioned, but not cardiogenic. Granted she is fairly young however pregnancies take quiet the toll on the human body. I remember seeing a video of a young mother who developed cardiomyopathy that began in the 1st pregnancy and worsened in the second requiring her to receive a pacemaker.

Cardiogenic shock would present similar to this; i.e. hypotension and signs of poor perfusion which she has.

The "sincher" as to this not being cardiogenic shock is the lack of an immediately identifiable cause and her wheezy chest. The most common causes of cardiogenic shock are VT and AMI. Her ECG is unremarkable for MI and is sinus tachycardia. It would however likely be incredibly uncommon for such a young person with no history of disposing factors, such as family history, viral carditis etc, to develop cardiomyopathy.

The distinction however for ambulance personnel is not clinically significant.

With that said the onset of symptoms where fairly quick, i'm just suprised no one dug for more of a history? I know normally we probe for a more detailed history before providing possible differentials. Am I missing something?

Yes. You are missing that developing further differentials will not change your treatment in a clinically significant way.

The two most important diagnoses not to miss here are (a) active antepartum haemorrhage, and (b) anaphylaxis, or anaphylaxis like syndrome.

We have very good evidence to point us away from antepartum haemoorhage (see my earlier post).

The diagnosis often depends upon the history, but in this case, a detailed history is inappropriate as the patient has an immediately life threatening problem and we've got enough of a history to combine with physical findings to come up with a diagnosis.